Delayed tooth eruption: Pathogenesis, diagnosis, and ...

REVIEW ARTICLE

Delayed tooth eruption: Pathogenesis,
diagnosis, and treatment. A literature review

Lokesh Suri, BDS, DMD, MS,a Eleni Gagari, DDS, DMSc,b and Heleni Vastardis, DDS, DMScc
Boston, Mass

Delayed tooth eruption (DTE) is the emergence of a tooth into the oral cavity at a time that deviates
significantly from norms established for different races, ethnicities, and sexes. This article reviews the local
and systemic conditions under which DTE has been reported to occur. The terminology related to
disturbances in tooth eruption is also reviewed and clarified. A diagnostic algorithm is proposed to aid the
clinician in the diagnosis and treatment planning of DTE. The sequential and timely eruption of teeth is critical
to the timing of treatment and the selection of an orthodontic treatment modality. This review addresses the
need for a more in-depth understanding of the underlying pathophysiology of DTE and gives the clinician a
methodology to approach its diagnosis and treatment. (Am J Orthod Dentofacial Orthop 2004;126:432-45)

Eruption is the axial movement of a tooth from the terminology used and the pathogenesis of DTE.
its nonfunctional position in the bone to func- Here, we propose to systematically review the literature
tional occlusion. However, eruption is often for reports on the diagnosis and treatment of DTE, to
used to indicate the moment of emergence of the tooth classify the etiology and pathogenesis of DTE, and to
into the oral cavity. The normal eruption of deciduous clarify the relevant terminology.
and permanent teeth into the oral cavity occurs over a
broad chronologic age range. Racial, ethnic, sexual, and DEFINITIONS AND TERMINOLOGY
individual factors can influence eruption and are usu-
ally considered in determining the standards of normal Many terms have been used in the literature to
eruption.1-3 True and significant deviations from ac- describe disorders of tooth eruption (Table I). There
cepted norms of eruption time are often observed in seems to be considerable confusion concerning their
clinical practice. Premature eruption has been noted,4,5 usage. Eruption is the developmental process responsi-
but delayed tooth eruption (DTE) is the most com- ble for moving a tooth from its crypt position through
monly encountered deviation from normal eruption the alveolar process into the oral cavity to its final
time. position of occlusion with its antagonist. It is a dynamic
process that encompasses completion of root develop-
Eruption is a physiologic process that strongly ment, establishment of the periodontium, and mainte-
influences the normal development of the craniofacial nance of a functional occlusion.2 Emergence, on the
complex.2,6 Often, DTE might be the primary or sole other hand, should be reserved for describing the
manifestation of local or systemic pathology.7 A delay moment of appearance of any part of the cusp or crown
in eruption can directly affect the accurate diagnosis, through the gingiva. Emergence is synonymous with
overall treatment planning, and timing of treatment for moment of eruption, which is often used as a clinical
the orthodontic patient. Thus, DTE can have a signifi- marker for eruption.
cant impact on a patient’s proper health care.
Impacted teeth are those prevented from erupting
The importance of DTE as a clinical problem is by some physical barrier in their path. Common factors
well reflected by the number of published reports on the in the etiology of impacted teeth include lack of space
subject, but there is considerable controversy regarding due to crowding of the dental arches or premature loss
of deciduous teeth. Frequently, rotation or other posi-
From the School of Dental Medicine, Tufts University, Boston, Mass. tional deviation of tooth buds results in teeth that are
aAssistant professor, Department of Orthodontics. “aimed” in the wrong direction, leading to impaction.
bAssociate professor, Department of Oral and Maxillofacial Pathology. Primary retention has been used to describe the cessa-
cResearch assistant professor, Department of Orthodontics. tion of eruption of a normally placed and developed
Reprint requests to: Dr Lokesh Suri, Tufts University, School of Dental tooth germ before emergence, for which no physical
Medicine, Department of Orthodontics–DHS-2, One Kneeland St, Boston, MA barrier can be identified.8,9
02111; e-mail, [email protected]
Submitted, June 2003; revised and accepted, October 2003. Pseudoanodontia is a descriptive term that indi-
0889-5406/$30.00 cates clinical but not radiographic absence of teeth that
Copyright © 2004 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2003.10.031

432

American Journal of Orthodontics and Dentofacial Orthopedics Suri, Gagari, and Vastardis 433
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Table I. Delayed tooth eruption: terminology used in Rasmussen’s “retarded eruption” coincides with Beck-
the literature er’s and Gron’s “delayed eruption,” and that “late
eruption” is used when a tooth’s eruption status is
Delayed eruption compared with chronologic eruption times defined by
Impacted teeth population studies.
Primary retention
Embedded teeth The terms “depressed” and “impaired” eruption
Pseudoanodontia have also been used synonymously with delayed, late,
Late eruption or retarded eruption. However, most of these reports
Retarded eruption refer to comparisons of observed eruption times with
Arrested eruption the chronologic standards set by population studies.
Primary failure of eruption Thus, “late eruption” used by Rasmussen would de-
Misplaced teeth scribe these conditions best.
Displaced teeth
Impaired eruption Primary or idiopathic failure of eruption is a
Depressed eruption condition described by Profitt and Vig,13 whereby
Noneruption nonankylosed teeth fail to erupt fully or partially
Submerged teeth because of malfunction of the eruption mechanism.
Reinclusion/inclusion of teeth This occurs even though there seems to be no barrier to
Paradoxical eruption eruption, and the phenomenon is considered to be due
to a primary defect in the eruptive process.13-15 Terms
should normally be present in the oral cavity for the such as arrested eruption and noneruption have been
patient’s dental and chronologic age. In these cases, used interchangeably to describe a clinical condition
radiographic examination discloses the teeth in the that might have represented ankylosis, impaction, or
jaws. These persons might have retained their decidu- idiopathic failure of eruption. These terms refer more to
ous teeth; more commonly, the deciduous teeth have the pathogenesis of DTE than to the benchmarks that
been shed, but the permanent ones failed to erupt. define DTE.

Controversy exists in the literature about the use of Embedded teeth are teeth with no obvious physical
“delayed,” “late,” “retarded,” “depressed,” and “im- obstruction in their path; they remain unerupted usually
paired” eruption. Root development has been taken as a because of a lack of eruptive force.16,17 Submerged
basis for distinguishing some of these terms. In 1962, teeth and inclusion/reinclusion of teeth refer to a
Gron10 showed that, under normal circumstances, tooth clinical condition whereby, after eruption, teeth become
eruption begins when 3/4 of its final root length is ankylosed and lose their ability to maintain the contin-
established. However, at the moment of eruption, man- uous eruptive potential as the jaws grow.18,19 Such
dibular canines and second molars show more ad- teeth then seem to lose contact with their antagonists
vanced root development than the expected 3/4 of the and might eventually be more or less “reincluded” in
final root length, whereas mandibular central incisors the oral tissues. This condition should not be confused
and first molars show root development less than 3/4 of with chronologic delayed eruption, because the erup-
the expected final root length. Becker11 suggests that tion was normal according to both chronologic and
root development alone should be the basis for defining biologic parameters (root formation), but the process
the expected time of eruption for different teeth. Thus, was halted. Paradoxical eruption simply has been used
if an erupted tooth has less root development than the to represent abnormal patterns of eruption and can
expected 3/4 of length, its eruption is deemed prema- encompass many of the above conditions.18
ture, whereas if the tooth has developed more than the
root length expected for eruption and remains une- Although many terms are used to characterize DTE,
rupted, it should be defined as having delayed eruption. they all refer to 2 fundamental parameters that influence
this phenomenon: (1) expected tooth eruption time
Rasmussen and Kotsaki,12 on the other hand, sug- (chronologic age), as derived from population studies,
gest using established norms for mean eruption ages and (2) biologic eruption, as indicated by progression
calculated from population studies. According to them, of root development. Chronologic age has been used
when the emergence of a tooth is more than 2 standard quite often to describe DTE. The advantage of using
deviations (SDs) from the mean of established norms chronologic norms of eruption lies in the ease of use.
for eruption times, it should be considered delayed Although not necessarily representating biologic age,
eruption. However, the authors further propose the expected time of tooth eruption often helps in forming
terms “late” and “retarded” eruption, to be used on the a baseline for further clinical evaluation of a patient.
basis of root development. It would then seem that Eruptive movements are closely related clinically with

434 Suri, Gagari, and Vastardis American Journal of Orthodontics and Dentofacial Orthopedics
October 2004

tooth development.1,2,10,20 Tooth eruption begins after layed eruption of the associated teeth. The most com-
root formation has been initiated. During eruption of
teeth, many processes take place simultaneously: the mon supernumerary tooth is the mesiodens, followed
dental root lengthens, the alveolar process increases in by a fourth molar in the maxillary arch.16,17 Different
height, the tooth moves through the bone, and, in cases
of succedaneous teeth, there is resorption of the decid- forms of supernumerary teeth have been associated
uous tooth. These parameters are currently used as
clinical markers for orthodontic treatment planning. with different effects on the dentition; the tuberculate

We propose a classification scheme (Fig 1) that type is more common in patients with DTE, whereas
takes into account these parameters, allowing the clini-
cian to follow a diagnostic algorithm for DTE and its the conical form has been associated with displace-
etiology. In this scheme, we sequentially examine ment.22 Odontomas and other tumors (in both the
several aspects of tooth eruption. First, we examine the
patient’s age and clinically apparent dentition. We deciduous and permanent dentitions) have also been
define as chronologic DTE the eruption time that is occasionally reported to be responsible for DTE.23-28 In
greater than 2 SDs from the mean expected eruption
time for a specific tooth (chronologic norm of erup- many of these case reports, the DTE was actually the
tion). A second step includes determining the presence
or absence of a factor that adversely affects tooth alerting sign for diagnosing these conditions. Regional
development. This will prompt the clinician to consider
certain diseases that result in defects of tooth structure, odontodysplasia, also called “ghost teeth,” is an un-
size, shape, and color. If tooth development is unaf-
fected by any such factor, the third step is to consider usual dental anomaly that might result from a somatic
the patient’s dental age as evidenced by root formation.
Normal biologic eruption time is defined as tooth mutation or could be due to a latent virus in the
eruption that occurs when the dental root is approxi- odontogenic epithelium.17,29 Affected teeth exhibit a
mately 2/3 its final length. Delayed biologic eruption is
defined as tooth eruption that has not occurred despite delay or total failure in eruption. Their shapes are
the formation of 2/3 or more of the dental root. Thus, if
a patient has chronologic delayed eruption, he or she markedly altered, generally very irregular, often with
might simply be of a dental age that does not fit the
norms (root length less than 2/3). evidence of defective mineralization. Central incisors,

In Tables II and III, we attempt to categorize lateral incisors, and canines are the most frequently
different conditions associated with DTE on the basis
of hypothesized mechanisms. Further division into affected teeth, in either the maxillary or mandibular
separate categories is also suggested to help in the
classification and diagnostic scheme. arch, and deciduous and permanent teeth can be affect-
ed.17 Abnormality in the tooth structure itself might be
PATHOGENESIS AND DIFFERENTIAL DIAGNOSIS
responsible for the eruptive disorders seen in this
The process of normal eruption and the source of
eruptive forces are still controversial topics. This sec- condition.
tion reviews reported mechanisms that lead to DTE in
some local and systemic conditions. Mucosal barrier has also been suggested as an
etiologic factor in DTE.28,30-32 Any failure of the
Local conditions
follicle of an erupting tooth to unite with the mucosa
Local conditions causing DTE are listed in Table II.
Physical obstruction is a common local cause of DTE will entail a delay in the breakdown of the mucosa and
of at least 1 tooth. These obstructions can result from
many different of causes, such as supernumerary teeth, constitute a barrier to emergence. Histologic studies
mucosal barrier, scar tissue, and tumors. DTE has been
reported to occur in 28% to 60% of white people with have shown differences in the submucosa between
supernumerary teeth.21 Supernumerary teeth can cause
crowding, displacement, rotation, impaction, or de- normal tissues and tissues with a history of trauma or
surgery.30 Gingival hyperplasia resulting from various

causes (hormonal or hereditary causes, vitamin C defi-

ciency, drugs such as phenytoin) might cause an abun-

dance of dense connective tissue or acellular collagen
that can be an impediment to tooth eruption.33 Injuries

to deciduous teeth have also been implicated as a cause
of DTE of the permanent teeth. Smith and Rapp,34 in a

cephalometric study of the developmental relationship

between deciduous and permanent maxillary central

incisors, found that the bony tissue barrier between the

deciduous incisor and its successor has a thickness of

less than 3 mm. This intimate relationship between the

permanent and deciduous incisors is maintained during

the developmental years. Traumatic injuries can lead to
ectopic eruption35,36 or some disruption in normal
odontogenesis in the form of dilacerations37,38 or phys-
ical displacement of the permanent germ.35,36 Cystic

transformation of a nonvital deciduous incisor might

also cause delay in the eruption of the permanent
successor.39 In some instances, the traumatized decid-

uous incisor might become ankylosed or delayed in its

American Journal of Orthodontics and Dentofacial Orthopedics Suri, Gagari, and Vastardis 435
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Fig 1. A diagnostic algorithm for DTE.

436 Suri, Gagari, and Vastardis American Journal of Orthodontics and Dentofacial Orthopedics
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Table II. Conditions reported in literature to be associated with DTE

Local Systemic

Mucosal barriers-scar tissue: trauma/surgery (28,30-32) Nutrition (51-53,128)
Gingival fibromatosis/ gingival hyperplasia (33) Vitamin D-resistant rickets (17,83)
Supernumerary teeth (116-119) Endocrine disorders (54-58,129)
Odontogenic tumors (eg, adenomatoid odontogenic tumors, Hypothyroidism (cretinism)
Hypopituitarism
odontomas) (23-28,120) Hypoparathyroidism
Nonodontogenic tumors (16,17) Pseudohypoparathyroidism
Enamel pearls (121) Long-term chemotherapy (130)
Injuries to primary teeth (122) HIV infection (61,62)
Ankylosis of deciduous teeth (38,44,45) Cerebral palsy (63)
Premature loss of primary tooth (36,38,42) Dysosteosclerosis (131)
Lack of resorption of deciduous tooth (40,41) Drugs
Apical periodontitis of deciduous teeth (38,39) Phenytoin (132,133)
Regional odontodysplasia (29) Anemia (65)
Impacted primary tooth (123) Celiac disease (134)
Ectopic eruption Prematurity/low birth weight (59,60)
Arch-length deficiency and skeletal pattern (48,77) Ichthyosis (83)
Radiation damage (49,124) Other systemic conditions: renal failure (66), cobalt/lead
Oral clefts (125,126)
Segmental odontomaxillary dysplasia (127) or other heavy metal intoxication (135), exposure to
hypobaria (64)
Numbers in parentheses are reference citations. Genetic disorders
Familial/inherited (12,136-138)
Tobacco smoke (139)
Idiopathic (140)

root resorption.40,41 This also leads to the overretention Arch-length deficiency might lead to DTE, although
of the deciduous tooth and disruption in the eruption of more frequently the tooth erupts ectopically.
its successor. The eruption of the succedaneous teeth is
often delayed after the premature loss of deciduous X-radiation has also been shown to impair tooth
teeth before the beginning of their root resorption. This eruption. Ankylosis of bone to tooth was the most
can be explained by the abnormal changes that might relevant finding in irradiated animals. Root formation
occur in the connective tissue overlying the permanent impairment, periodontal cell damage, and insufficient
tooth and the formation of thick, fibrous gingiva.38,42 mandibular growth also seem to be linked to tooth
Ankylosis, resulting from the fusion of the cementum eruption disturbances due to x-radiation.49,50 Occasion-
or dentin with the alveolar bone, is the most common ally, localized DTE might be idiopathic.
local cause of delayed deciduous tooth exfolia-
tion.8,9,43-45 Ankylosis occurs commonly in the decid- Systemic conditions
uous dentition, usually affecting the molars, and has
been reported in all 4 quadrants, although the mandible Systemic conditions causing DTE are listed in
is more commonly affected than the maxilla. Anky- Table II. The influence of nutrition on calcification and
losed teeth will remain stationary while adjacent teeth eruption is less significant compared with other factors,
continue to erupt through continued deposition of because it is only at the extremes of nutritive depriva-
alveolar bone, giving the clinical impression of infraoc- tion that the effects on tooth eruption have been
clusion.9,43,46,47 shown.51-53 Nevertheless, delayed eruption is often
reported in patients who are deficient in some essential
Arch-length deficiency is often mentioned as an nutrient. The high metabolic demand on the growing
etiologic factor for crowding and impactions.8,9 In a tissues might influence the eruptive process.52,53 Dis-
recent study of the relationship between formation and turbance of the endocrine glands usually has a profound
eruption of the maxillary teeth and the skeletal pattern effect on the entire body, including the dentition.
of the maxilla, a shortened palatal length was found to Hypothyroidism, hypopituitarism, hypoparathyroidism,
delay the eruption of the maxillary second molar, and pseudohypoparathyroidism are the most common
although no delay in tooth formation was observed.48 endocrine disorders associated with DTE. In hypothy-
roidism, failure of thyrotropic function on the part of

American Journal of Orthodontics and Dentofacial Orthopedics Suri, Gagari, and Vastardis 437
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Table III. Genetic disorders associated with DTE the pituitary gland or an atrophy or destruction of the
thyroid gland per se leads to cretinism (congenital
Amelogenesis imperfecta (141) and associated disorders (115) hypothyroidism) in a growing person. The dentofacial
Enamel agenesis and nephrocalcinosis changes in cretinism are related to the degree of thyroid
Amelo-onychohypohydrotic dysplasia deficiency.54-56 In hypopituitarism or pituitary dwarf-
Tricho dento-osseous syndrome (types I and II) ism, the eruption and shedding of the teeth are delayed,
as is the growth of the body in general.54,57,58 The
Apert syndrome (67,68) dental arch has been reported to be smaller than normal;
Carpenter syndrome (81) thus it cannot accommodate all the teeth, so a maloc-
Cherubism (7) clusion develops. The roots of the teeth are shorter than
Chondroectodermal dysplasia (Ellis-van Creveld syndrome) (17) normal in dwarfism, and the supporting structures are
Cleidocranial dysplasia (142) retarded in growth.
Congenital hypertrichosis lanuginosa (143)
Dentin dysplasia (144) Retardation of dental growth and development in
Mucopolysaccharidosis (MPS) preterm babies has been reviewed by Seow59 and
identified as a cause of DTE. Teething is often delayed,
DeLange syndrome (83) and Seow’s results have shown a distinct relationship
Hurler syndrome (MPS I-H) (17,69,145) between birth weight and numbers of erupted teeth.
Hurler Scheie syndrome (MPS I-H/S) (9) DTE is common in preterm babies with respect to the
Hunter syndrome (MPS II) (9) deciduous dentition, but “catch-up” development oc-
Pyknodysostosis (Maroteaux-Lamy syndrome) (MPS IV) (17) curred in later infancy. The permanent teeth showed a
Down syndrome (146) significant mean delay in dental maturation of approx-
Dyskeratosis congenita (147) imately 3 months in very low birth-weight babies (birth
Ectodermal dysplasia (83) weight of Ͻ1500 g). In another study, Seow60 found
Ekman-Westborg-Julin syndrome (148) that children with a birth weight less than 1000 g and
Epidermolysis bullosa (149) gestational ages less than 30 weeks had the greatest lag
GAPO syndrome (growth retardation, alopecia, pseudoanodontia, in dental maturation. A correlation between human
and optic atrophy) (69) immunodeficiency virus (HIV) infection and DTE
Gardner syndrome (71,74) has also been suggested. A study61 of dental mani-
Gaucher disease (150) festations in 70 children perinatally infected with
Gingival fibromatosis associated syndromes (9) HIV indicates that delayed dental eruption (defined
Laband syndrome as dental age 6 or more months younger than
Murray-Puretic-Drescher syndrome chronologic age) was directly associated with clini-
Rutherford syndrome cal symptoms. DTE did not seem to correlate with
Cross syndrome CD4 positive T-lymphocyte depletion. The investi-
Ramon syndrome gators concluded that HIV infection itself is not
Gingival fibromatoses with sensorineural hearing loss associated with DTE, but, rather, the onset of the
Gingival fibromatoses with growth hormone dificiency clinical symptoms is. Another study62 has found that
Gorlin syndrome (151) a lower tooth count at different chronologic ages in
Hallermann-Streiff syndrome (69,152) HIV-infected children might represent a marker for
Hyperimmunoglobulinemia E (Buckley syndrome) (83) socioeconomic status, reflecting poorer nutrition or
I-cell disease (mucolipidosis II) (153) health. In a study of children with cerebral palsy,
Incontinentia pigmenti (Bloch-Sulzberger syndrome) (154) Pope and Curzon63 found that unerupted deciduous
Mc-Cune-Albright syndrome (polyostotic fibrous dysplasia) (17) and permanent teeth were more common in them
Menkes’ kinky hair syndrome (155) compared with the controls. The first permanent
Neurofibromatoses (156,157) molar erupted significantly later. No etiology or
Oculoauriculo vertebral spectrum (Goldenhar syndrome/hemifacial implicated mechanisms were elaborated.
microsomia) (69,158)
Osteoglophonic dyspalsia (69) Other systemic conditions associated with impair-
Osteopathia striata with cranial stenosis (69,159) ment of growth, such as anemia (hypoxic hypoxia,64
Osteopetrosis (marble bone disease) (78,79) histotoxic hypoxia, and anemic hypoxia65) and renal
Osteogenesis imperfecta (160,114) failure,66 have also been correlated with DTE and other
Otodental dysplasia (161) abnormalities in dentofacial development.
Parry-Romberg syndrome (progressive hemifacial atrophy) (162)
Progeria (Hutchinson-Gilford syndrome) (17,69)
Rothmund-Thompson syndrome (9,69)
Sclerosteosis (80)
Shokier syndrome (hereditary anodontia spuria)
SHORT syndrome (9,69)
Singleton-Merten syndrome (163)
VonRecklinghausen neurofibromatosis (164)
22q11 deletion syndrome (165)

Numbers in parentheses are reference citations.

438 Suri, Gagari, and Vastardis American Journal of Orthodontics and Dentofacial Orthopedics
October 2004

Genetic disorders This could explain the frequency of DTE in posterior
teeth. Some patients who have delayed eruption of the
Genetic disorders causing DTE are listed in Table second molars alone might fall into the category of mild
III. DTE has been found to be a feature in many genetic eruption failure syndrome.13
disorders and syndromes. Various mechanisms have
been suggested to explain DTE in these conditions. A CLINICAL IMPLICATIONS
generalized developmental delay in permanent tooth
formation is seen in Apert syndrome.67,68 Supernumer- Accurate diagnosis of DTE is an important but
ary teeth have been found to be responsible for DTE in complicated process. When teeth do not erupt at the
Apert syndrome,67,69 cleidocranial dysostosis,70 and expected age (mean Ϯ 2 SD), a careful evaluation
Gardner syndrome.71 There is considerable evidence to should be performed to establish the etiology and the
implicate the periodontal tissues’ development in DTE. treatment plan accordingly. The importance of the
Abnormalities in these tissues, as have been found in patient’s medical history cannot be overstated. A wide
some syndromes, might be a factor in DTE. Lack of variety of disorders has been reported in the literature to
cellular cementum has been found in cleidocranial be associated with DTE (Tables II and III). Family
dysplasia72,73; cementum-like proliferations and oblit- information and information from affected patients
eration of periodontal-ligament space with resultant about unusual variations in eruption patterns should be
ankylosis have been noted in Gardner syndrome.74 investigated. Clinical examination should be done me-
Tooth eruption is also regulated by various cytokines, thodically and must begin with the overall physical
including epidermal growth factor,75 transforming evaluation of the patient. Although the presence of
growth factor-␤, interleukin-1, and colony stimulating syndromes is usually obvious, in the mild forms, only a
factor-1.75-77 Lack of appropriate inflammatory re- careful examination will reveal the abnormalities.
sponse, an inadequate expression of some cytokines, Right-left variations in eruption timings are minimal in
and increased bone density that impedes resorption most patients, but significant deviations might be asso-
have been noted to be factors for DTE in some ciated with (for example) tumors or hemifacial micro-
syndromes. In osteopetrosis,78,79 sclerosteosis,80 Car- somia or macrosomia and should alert the clinician to
penter syndrome,81 Apert syndrome,67,68 cleidocranial perform further investigation.
dysplasia,82 pyknodysostosis,17 and others, underlying
defects in bone resorption and other operating mecha- Intraoral examination should include inspection,
nisms might be responsible for DTE. Conversely, bone palpation, percussion, and radiographic examination.
resorption is enhanced in hyperimmunoglobulin E syn- The clinician should inspect for gross soft tissue pa-
drome, but DTE has been noted as a feature of this thology, scars, swellings, and fibrous or dense frenal
condition. This has been suggested to be due to defec- attachments. Careful observation and palpation of the
tive root resorption of the deciduous teeth or the alveolar ridges buccally and lingually usually shows the
presence of a protective factor on the root that resists characteristic bulge of a tooth in the process of erup-
physiologic resorption.83 Tumors and cysts in the jaws tion. Palpation producing pain, crackling, or other
can also cause interference with tooth eruption. Occa- symptoms should be further evaluated for pathology. In
sionally, some syndromes or genetic disorders are patients in whom a deciduous tooth is overretained,
associated with multiple tumors or cysts in the jaws, with respect to either the contralateral side or the mean
and these might lead to generalized DTE. Gorlin exfoliation age for the patient’s sex and ethnicity, the
syndrome, cherubism, and Gardner syndrome are such deciduous tooth and the supporting structures should be
disorders, in which DTE might be the result of inter- thoroughly examined.53 Ankylosed teeth also interfere
ference to eruption by these lesions. Occasionally, with the vertical development of the alveolus.8,9,44
families are found in which a generalized delay in the Retention of the deciduous tooth might lead to deflec-
eruption of teeth is noted. Patient medical history might tion of the succedaneous tooth and resorptive damage
be totally unremarkable, with DTE as the only finding. of the adjacent teeth.84
The presence of a gene for tooth eruption has also been
suggested, and its “delayed onset” might be responsible Schour and Massler,1 Nolla,2 Moorrees et al,3,85
for DTE in “inherited retarded eruption.”12 Delayed and Koyoumdjisky-Kaye et al86 have developed tables
development of isolated teeth has also been reported. and diagrammatic charts of the stages of tooth devel-
This is most commonly seen in the premolar region. opment, starting from the initiation of the calcification
Profitt and Vig13 hypothesized that a “gradient of process to the completion of the root apex of each
eruption” might exist distally along the dental lamina. tooth. Norms with the average chronologic ages at
which each stage occurs are also provided. Root devel-
opment, with few exceptions, proceeds in a fairly
constant manner.10,11

American Journal of Orthodontics and Dentofacial Orthopedics Suri, Gagari, and Vastardis 439
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DTE is often seen in the region of the maxillary THERAPEUTIC CONSIDERATIONS FOR THE
canines.87-90 The maxillary canine develops high in the PATIENT WITH DTE
maxilla and is the only tooth that must descend more
than its length to reach its position in the dental arch. DTE presents a challenge for orthodontic treatment
When pathologic conditions are ruled out, the etiology planning. A number of techniques have been suggested
of DTE of the canines has been suggested to be for treating DTE. The main considerations for teeth
multifactorial.9,91,92 Specifically, 3 factors have been affected by DTE are (1) the decision to remove or retain
proposed for consideration: (1) DTE of the canine the tooth or teeth affected by DTE, (2) the use of
might simply reflect ectopic development of the tooth surgery to remove obstructions, (3) surgical exposure
germ that could be genetically determined, (2) there of teeth affected by DTE, (4) the application of ortho-
might be a familial association to them, and (3) in a dontic traction, (5) the need for space creation and
significant number of cases of delayed eruption of the maintenance, and (6) diagnosis and treatment of sys-
canine, an abnormality of the lateral incisor in the same temic disease that causes DTE.
quadrant is observed.90,93 According to Becker et
al,94,95 abnormalities of the lateral incisor occur so The treatment flowchart (Fig 2) can serve as a
frequently in cases of delayed canine eruption that the guideline for addressing the most important treatment
association is not likely to be due to chance.94,95 A options in DTE. Once the clinical determination of
developmental anomaly might exist in this part of the chronologic DTE (Ͼ2 SD) has been established, a
maxilla, which contains one of the embryonic fusion panoramic radiograph should be obtained. The screen-
lines, and DTE of the canines in many cases could be ing radiograph can be used to assess the developmental
part of a hereditary syndrome.90 state of the tooth and rule out tooth agenesis.

Permanent tooth agenesis (excluding the third mo- DTE with defective tooth development
lars) in the general population has been noted to range
from 1.6% to 9.6%. The incidence of tooth agenesis in If there is defective tooth formation, the first step
the deciduous dentition is in the range of 0.5% to should be to assess whether the defect is localized or
0.9%.96 After third molars, the most commonly missing generalized.
teeth are mandibular second premolars and maxillary
lateral incisors, in that order.16 Thus, congenital ab- In the deciduous dentition, close observation of the
sence of a tooth should also be suspected when consid- defective deciduous tooth or teeth is the usual course of
ering DTE. treatment, and space should be maintained where indi-
cated. Unerupted deciduous teeth with serious defects
A panoramic radiograph is ideal for evaluating the should be extracted, but the time of extraction should
position of teeth and the extent of tooth development, be defined carefully by considering the development of
estimating the time of emergence of the tooth into the the succedaneous teeth and the space relationships in
oral cavity, and screening for pathology. The parallax the permanent dentition. Information in the literature is
method (image/tube shift method, Clark’s rule, buccal sparse on this topic, either because the condition is
object rule) and 2 radiographs taken at right angles to underreported or because defective tooth development
each other97,98 are suggested for radiographic localiza- is primarily diagnosed in the permanent dentition.
tion of tumors, supernumerary teeth, and displaced
teeth, which require surgical correction. Computed In the permanent dentition, unerupted teeth are
tomography can be used as the most precise method of normally closely observed until the skeletal growth
radiographic localization, although its additional cost period necessary for appropriate development and pres-
and relatively high radiation dose limit its use.97,99 ervation of the surrounding alveolar ridge has been
attained. Management has traditionally focused on the
DTE can also have psychological implications for restorative challenges of these patients once the teeth
the patient, especially if anterior teeth are affected. The have erupted.16 No systematic approach to accelerate
duration of orthodontic treatment might be prolonged the eruption of malformed retained teeth could be found
while the orthodontist and the patient wait for tooth in the literature. However, Andreasen9 suggests that in
eruption. In such situations, adequate space should be patients in whom the defect is not in the supporting
maintained and a reevaluation for possible systemic apparatus of the tooth, exposure of the affected teeth
influences should be performed. When there are coex- might bring about the eruption. Severely malformed
isting systemic conditions, factors such as bone quality, teeth usually must be extracted.16 Often, defective teeth
bone density, and skeletal maturation also should be can serve as abutments for restorative care once they
considered. have erupted.16,100

440 Suri, Gagari, and Vastardis American Journal of Orthodontics and Dentofacial Orthopedics
October 2004

Fig 2. Flow chart of treatment options for DTE affecting permanent dentition.

American Journal of Orthodontics and Dentofacial Orthopedics Suri, Gagari, and Vastardis 441
Volume 126, Number 4

DTE with no obvious developmental defect in the cause obstruction, the surgical approach is dictated by
affected tooth or teeth on the radiograph the biologic behavior of the lesion. If the affected tooth
is deep in the bone, the follicle around it should be left
In this case, root development (biologic eruption intact. When the affected tooth is in a superficial
status), tooth position, and physical obstruction (radio- position, exposure of the enamel is done at tumor
graphically evident or not) should be evaluated. removal.9,16,38 Occasionally, the affected tooth must be
removed. Four surgical approaches have been recom-
In the absence of ectopic tooth position and physi- mended for uncovering impacted teeth.106-109 These
cal obstruction, and if the biologic eruption status is include gingivectomy, apically positioned flap, flap/
within normal limits, periodic observation is the rec- closed eruption, and the preorthodontic uncovering
ommended course of action. For a succedaneous tooth technique.106 Two opinions seems to exist regarding
if root formation is inadequate, extraction of the decid- management of the tooth delayed in eruption after
uous tooth or exposure to apply active orthodontic removing the physical barrier. McDonald and Avery110
treatment is not justified.10,11 Root development should recommend exposure of the tooth delayed in eruption at
be followed by periodic radiographic examination. If the surgical removal of the barrier, but Houston and
the tooth is lagging in its eruption status, active treat- Tulley111 advocate removing the obstruction and pro-
ment is recommended when more than 2/3 of the root viding sufficient space for the unerupted tooth to erupt
has developed. spontaneously. Most teeth (54%-75%) erupt spontane-
ously in the latter situation; however, the eruption rate
Radiographic examination might also show an ec- might be protracted.112 DiBiase112 reported that if the
topic position of the developing tooth. Often, some tooth is not displaced and its follicle not disturbed
deviations self-correct,101 but significant migration of during the surgical procedure, the tooth might take an
the tooth usually requires extraction.102 If self-correc- average of 18 months to erupt. DiBiase112 also stated
tion is not observed over time, active treatment should that sufficient space should be made available for the
begin. Exposure accompanied by orthodontic traction tooth’s eruption. If the tooth is exposed at the time of
has been shown to be successful. In patients in whom surgery, it might or might not be subjected to orthodon-
the ectopic teeth deviate more than 90° from the normal tic traction to accelerate and guide its eruption into the
eruptive path, autotransplantation might be an effective arch.9,106 The decision to use orthodontic traction in
alternative.9 most case reports seems to be a judgment call for the
clinician. No conclusive guidelines could be derived
An obstruction causing delayed eruption might or from the literature regarding when active force should
might not be obvious on the radiographic survey. A soft be used to aid eruption of the exposed tooth. Occasion-
tissue barrier to eruption is not discernible on the ally, a deciduous tooth can be a physical barrier to the
radiograph, but, regardless of etiology, an obstruction eruption of the succedaneous tooth.34,38,47 In most
should be treated with an uncovering procedure that cases, removing the deciduous tooth will allow for
includes enamel exposure.9,30,38 Supernumerary teeth, spontaneous eruption of the successor. When arch-
tumors, cysts, and bony sequestra are examples of length deficiency creates a physical obstruction, either
physical obstructions visible on the radiographic sur- expansion of the dental arches or extraction might be
vey. Their removal usually will permit the affected necessary to obtain the required space. Extraction of
tooth to erupt. either the affected or adjacent teeth can be performed.9

In the deciduous dentition, DTE due to obstruction Occasionally, several teeth in a quadrant might be
is uncommon, but scar tissue (due to trauma) and unerupted, and this can present an orthodontic chal-
pericoronal odontogenic cysts or neoplasms are the lenge because of the lack of adequate anchorage ele-
usual culprits in cases of obstruction. Trauma is more ments. Osseointegrated implants might offer viable
common in the anterior region, but cysts or neoplasms alternatives for anchorage in such cases.113
are more likely to result in DTE in the canine and molar
regions.23 Odontomas are reported to be the most DTE associated with systemic disorders
common of the odontogenic lesions associated with
DTE.103,104 Treatment options for deciduous DTE Whenever DTE is generalized, the patient should be
range from observation, removal of physical obstruc- examined for systemic diseases affecting eruption, such
tion with and without exposure of the affected tooth, as endocrine disorders, organ failures, metabolic disor-
orthodontic traction on rare occasions, and extraction of ders, drugs, and inherited and genetic disorders. Vari-
the involved tooth.23,103,105 ous methods have been suggested for treating eruption
disorders in these conditions. These include no treat-
In the permanent dentition, removal of the physical
obstruction from the path of eruption is recommended.
When neoplasms (odontogenic or nonodontogenic)

442 Suri, Gagari, and Vastardis American Journal of Orthodontics and Dentofacial Orthopedics
October 2004
ment (observation), elimination of obstacles to eruption
(eg, cysts, soft tissue overgrowths), exposure of af- 15. Pytlik W. Primary failure of eruption: a case report. Int Dent J
fected teeth with and without orthodontic traction, 1991;41:274-8.
autotransplantation, and control of the systemic dis-
ease.7,9,12,16,59,61,83,114,115 16. Neville BW, Damm DD, Allen CM. Oral and maxillofacial
pathology. Philadelphia: W.B. Saunders; 2002.
CONCLUSIONS
17. Shafer WG, Hine MK, Levy BM. Textbook of oral pathology.
Variation in the normal eruption of teeth is a Philadelphia: W.B. Saunders; 1983.
common finding, but significant deviations from estab-
lished norms should alert the clinician to further inves- 18. Spieker RD. Submerged permanent teeth: literature review and
tigate the patient’s health and development. Delayed case report. Gen Dent 2001;49:64-68.
tooth eruption might be a harbinger of a systemic
condition or an indication of altered physiology of the 19. Antoniades K, Kavadia S, Milioti K, Antoniades V, Markovitsi
craniofacial complex. Orthodontists are often in a E. Submerged teeth. J Clin Pediatr Dent 2002;26:239-42.
sentry position to perform an early evaluation of
craniofacial structures, both clinically and radiograph- 20. Moorrees CF, Gron AM, Lebret LM, Yen PK, Frohlich FJ.
ically. Proper evaluation of DTE in orthodontic diag- Growth studies of the dentition: a review. Am J Orthod
nosis and treatment requires a clear definition of the 1969;55:600-16.
term and its significance. We propose a diagnostic
“tree” that would enable the clinician to perform an 21. Tay F, Pang A, Yuen S. Unerupted maxillary anterior supernu-
accurate and thorough orthodontic diagnosis of the merary teeth: report of 204 cases. ASDC J Dent Child 1984;
patient with DTE. 51:289-94.

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